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Normative data for the Hospital Anxiety and Depression Scale
Suzanne Breeman1, Seonaidh Cotton1, Shona Fielding2, Gareth T Jones3
1 Health Services Research Unit, Division of Applied Health Sciences, University of
Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
2 Medical Statistics Team, Division of Applied Health Sciences, University of
Aberdeen, Polwarth Building, Foresterhill, AB25 2ZD, UK
3 Epidemiology Group, Institute of Applied Health Sciences, University of
Aberdeen, Polwarth Building, Foresterhill, AB25 2ZD, UK
Corresponding author:
Suzanne Breeman
Email: s.breeman@abdn.ac.uk
Tel: 01224 438169
Fax: 01224 438165;
1
Purpose
The Hospital Anxiety and Depression Scale (HADS) is widely used in both research
and clinical contexts. However UK normative data from HADS remains limited. In
our recent review of the literature, only six reports from four studies were identified as
reporting UK normative data and all had limitations. The aim of our study was to use
a large population-based dataset to address this.
Methods
The Epidemiology of Functional Disorders Study is a large longitudinal population-
based study carried out in Northwest England. All adults aged between 25 and 65
years registered with three general practices were sent a self-completion
questionnaire which contained the HADS and other health-related instruments.
Scores were calculated for participants completing all items on each sub-scale
(anxiety 6189 participants, depression 6198 participants). Scores are presented by
gender and by 5-year age-groups. Percentile scores were also generated.
Results
The median anxiety score was higher in women (6, IQR 4 to 9) than in men (5, IQR 2
to 8), and increased with age in both groups. The median depression score for both
women and men was 3 (IQR 1 to 6).
Conclusions
Our study is the largest population-based study providing UK normative data from
HADS. While our data confirms some of the normative data reported previously,
subtle and important differences emerged, particularly at the upper end of the
percentile scores. Due to the nature of our study design and the number of
1
participants sampled, we believe that our data is likely to be more representative of
the UK population than existing published normative values.
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Introduction
Patient reported outcome measures (PROMs) are extensively used in research and
medical practice to assess clinical outcomes such as health-related quality of life [1,
2]. They are a subjective measure and assess the outcome or health parameter from
the patient’s own perspective [1, 2]. In the field of mental health, PROMs have been
shown to provide unique and invaluable information [3]. One such instrument is the
Hospital Anxiety and Depression Scale (HADS) [4].
The HADS was originally developed by Zigmond and Snaith as a screening tool to
capture clinically significant states of anxiety and depression in a non-psychiatric
hospital setting [4]. The HADS was therefore designed to be a brief, 14-item, self-
assessment scale that was easily understandable and capable of distinguishing
between these emotional states [5].
The anxiety and depression sub-scales each consist of seven items with each item
having four possible answers scored 0, 1, 2 or 3. Individual anxiety and depression
scores are calculated by summation of the appropriate seven items and thus can
range from zero to twenty-one, with higher scores indicating higher levels of anxiety
or depression respectively.
In their initial publication, Zigmond and Snaith used clinical assessments to
recommend that a score of 0 to 7 on either sub-scale should be defined as a ‘non-
case’ (later defined as ‘normal’), a score of between 8 and 10 defined as a ‘doubtful
case’ (later defined as a ‘mild case’) and a score of more than or equal to 11 defined
as a ‘definitive case’ of anxiety or depression [4]. However they emphasised that
further research would be required to validate the suggested cut-off scores in
different clinical settings. Furthermore, in a more recent publication, the authors
suggest a third cut-off point, where a score of between 11 and 14 is defined as a
1
‘moderate’ case and a score of between 15 and 21 as a ‘severe’ case of anxiety or
depression [5]. However, no empirical data was presented on the usefulness of this
later cut-off score [5, 6].
Since its development the HADS has become a commonly used instrument in both
research and clinical practice. For example, a review published by Herrman in 1997
identified over 200 published papers which reported on the use of HADS in
approximately 35,000 participants [6]. The studies were conducted in 26 different
countries; the questionnaire translated into 33 different languages; and was used in
many different medical settings, for example general medicine, oncology and
cardiology. An updated review by Bjelland et al in 2002 reported that the number of
papers reporting HADS had since increased almost fourfold, highlighting the
continued use of the questionnaire in both standard medical practice and in health-
related research [7].
Despite its frequent use, normative data (i.e. data collected from a representative
sample of the general population against which all subsequently collected data can
be compared) has remained limited. Our recent review of the literature identified only
twenty papers that could be described as reporting normative data from HADS [8-27].
The studies were conducted mainly in Europe, included sample sizes ranging from
94 [17] to 62,344 [13] participants and were sourced using a variety of different
techniques, for example all residents in a particular region/country [13, 17, 19], a
stratified random sample of three age cohorts [12, 20] and adults registered with a
particular Primary Care practice [8, 10, 14].
Only six reports from four studies included UK participants [8, 12, 14, 15, 20, 24]. All
reports had limitations, mainly in terms of sample size and/or sample selection. One
of these studies [15] is recommended by the current licence holder (GL Assessment)
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as appropriate normative data for the UK. However the sampling technique
employed in this study (participants were drawn from commercial and public service
organisations, community centres and recreational clubs) means that the data is
unlikely to be representative of the general population, as it may only include those in
employment or engaged in community activities, who may have different
psychological morbidity from those that are not.
The aim of the current study was to establish normative HADS data for the UK
population using data from a large population based study which is likely to be
representative of the UK population.
Methods
The Epidemiology of Functional Disorders (EpiFunD) Study is a large longitudinal
population-based study carried out in Northwest England, the design and primary
results of which have been published previously [28, 29]. In brief, at baseline, all
patients registered with one of three general practices (although not necessarily
attending for treatment) were sent a self-completion questionnaire in 2001/02. The
practices were from different socio-economic areas, as assessed by the Townsend
index – a census-derived index of indicators of home ownership, car ownership,
unemployment and overcrowding [30]. The questionnaire included the HADS and
other health related instruments. Two weeks after the initial mailing, non-participants
were sent a reminder postcard, with another full questionnaire sent two weeks
subsequently to those who had still not responded. The study was approved by
South Manchester local research ethics committee and South Cheshire local
research ethics committee.
In this analysis, we report baseline data. All analyses were performed using the
statistical package Stata Version 10.0 (StataCorp, College Station, TX). To estimate
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the representativeness of the EpiFunD sample, the age and gender profiles of the
sample was compared to UK national estimates (2001 Census data [31]). The
internal validity of the sample were then assessed by comparing response rates by
gender and age using the Chi-Square test.
Anxiety and Depression scores
Anxiety and depression scores were calculated for those who had completed all
items on the anxiety and depression sub-scales respectively (complete case
analysis). A priori, we hypothesised that scores would differ by gender and age [8-
27]; this was confirmed in the initial analysis and thus results are presented for
females and males separately, and within gender, by 5-year age-group.
As the anxiety and depression scores were skewed towards lower scores (positively
skewed distribution), median scores with the associated Interquartile Range (IQR)
were deemed the most appropriate descriptive statistic to present. However to aid
comparisons with other studies, data is presented here in four ways: (1) median
scores with IQRs; (2) the proportion of patients in each of Zigmond and Snaith’s [4]
original normal, mild and moderate to severe classifications; (3) percentile scores
and; (4) mean scores with the associated Standard Deviations (SD).
Results
Profile of EpiFunD sample versus Census data
The EpiFunD baseline questionnaire was issued to 10,987 adults and had a
response rate of 68.2% (after adjusting for deaths and those not resident at the given
address) [30]. Of those issued with the questionnaire, 50.2% were female and
49.8% were male. These proportions were similar to the 2001 Census data which
showed that 50.7% of UK adults aged between 25 and 65 years of age were female
4
[31]. The age distribution of those sent the questionnaire was also similar to that
reported in the 2001 Census data [31].
Profile of responders
Response rates were higher in women (64.3%) than men (49.8%) (p<0.001) and
generally increased with increasing age (41.3% in the youngest group to 72.1% in
the oldest group; p<0.001). The participants that returned the questionnaire were
also younger when compared to non-responders (mean age 45.9 (SD 11.0) versus
42.0 (SD 10.6)). The baseline characteristics of the responders are shown in Table 1.
Level of missing data
Of the 6,280 participants who completed the questionnaire, 1.4% (91) of the
participants failed to complete all seven items which contribute to the anxiety score
and 1.3% (82) failed to complete all seven items which contribute to the depression
score. Imputation of missing data for those participants that had missed one or two
items on the anxiety scale (50 and three participants respectively) or had missed one
or two items on the depression scale (40 and 13 participants respectively) had
minimal impact on the reported scores and prevalence rates. The results presented
below are therefore based on a complete case analysis only.
Anxiety
The median anxiety scores were significantly higher among women (6, IQR 4 to 9)
than among men (5, IQR 2 to 8; p<0.001; Table 2). Similarly, the percentage of
those classified as having ‘moderate to severe’ anxiety (anxiety score ≥11) was
higher among women (19.0%) than among men (12.5%; p<0.001). In both women
and men, the median anxiety scores and the prevalence of ‘moderate to severe’
anxiety decreased with increasing age, although this was not statistically significant.
The anxiety scores are presented as percentiles for women and men separately
5
(Figure 1). For comparison, these are plotted together with the percentile data from
Crawford et al [15], the study providing the currently recommended normative data
from the UK.
Depression
The median depression scores were the same for both women and men (3, IQR 1 to
6; Table 3). The percentage of those classified as having ‘moderate to severe’
depression (depression score ≥11) was also the same among women (6.9%) and
men (6.9%), although the percentage of those classified as having any level of
depression (depression score >8) was higher among women (17.2%) than in men
(15.4%). In both men and women, the percentage of those classed as having
‘moderate to severe’ depression had an apparent bell-shape with respect to age, with
the highest prevalence seen in participants in their forties and early fifties. Percentile
data is shown in Figure 2, and plotted together with the percentile data from Crawford
et al [15].
Discussion
The EpiFunD study was used as a means to expand the available UK normative data
for HADS. This study is a large population-based study that invited all adults, aged
between 25 and 65 years of age, who were registered with three primary care
practices in the North-West of England, to participate [32]. This invited group were
shown to be broadly representative of the UK population in terms of age and gender
when compared to the 2001 Census statistics.
Compared to men, response rates were higher in women, as were anxiety scores.
Thus, combining the anxiety scores for men and women would result in artificially
inflated summary measures for men and artificially reduced summary measures in
woman. For this reason (and our a priori hypothesis that scores would differ by
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gender), we have not combined the data and have presented summary scores for
men and women separately. Response rates also varied by age, as did anxiety and
depression scores, and combined these factors have the potential to distort the
findings of the study if presenting single normative values across different ages and
genders.
Strengths and limitations of the study
A particular strength of this study is the sample size, which is more than three times
greater than the study recommended as providing normative data for the UK [15] and
which allows us to report summary scores by gender and 5-year age-groups.
Furthermore, we suggest that those completing the HADS as part of the EpiFunD
study are likely to be more representative of the general population than participants
of the study providing the currently recommended normative data from the UK [15],
particularly because of the different sampling techniques. Crawford et al drew their
sample from commercial and public service organisations, community centres and
recreational clubs [15]. By comparison the EpiFunD sample was drawn from the
registers of three primary care practices. It is estimated that 96% of the UK
population are registered with a GP [33] and, thus, sampling from GP registers
provides a convenient population sampling frame for health research and, arguably,
a more appropriate population from which to derive normative values of any health
instrument.
However, as the proportion of people over 60 years of age is reported to be growing
faster than any other age group in the UK [34], one limitation of this study is the age
range of the participants included: the EpiFunD sample only contained adults aged
25 to 65 years of age. Therefore, while this paper represents a population-based
sample of adults of working age, extrapolation to older adults is limited.
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Comparisons with current literature
We have confirmed some of the findings reported by Crawford et al [15]. For
example, we report the same median anxiety and depression scores for both men
and women. However, although there are similarities between our data and the data
from Crawford et al [15], there are subtle but important differences. For example, the
distributions of percentiles diverged at the upper end of the scores, with a greater
proportion of the EpiFunD sample having higher scores on each of the sub-scales
compared with the Crawford et al study [15]. There are a number of possible
explanations for this. Firstly, anxiety and depression scores vary by age, and the
Crawford et al study [15] included a higher proportion of younger participants (28% of
participants were aged 18-29 years) compared to the current study (where 8% of
participants were aged <30 years). However as noted previously, a strength of our
study is the sample size, which allows summary scores to be calculated by gender
and age group. Secondly, it is likely that those participating in the study by Crawford
et al, by their very nature (i.e. they are participating in activities or work outside the
home) have less psychological morbidity (and thus report lower anxiety and
depression scores) than those who do not participate in such activities (and who may
be included in our study) [35].
Conclusions
We have provided supplementary normative data for the HADS for the UK working
age population (25-65 years) using data collected as part of the EpiFunD study. We
believe that the data we report may be more representative of the general population
than previous studies. In addition, the sample size allows data to be presented not
only by gender but also by age-group. Such data will aid in the interpretation of other
studies that have used the HADS as a patient reported outcome measure.
8
Acknowledgements
The authors would like to thank all those involved in the EpiFunD study for their role
in collecting the data used in this study, particularly the principal investigators Gary
Macfarlane (University of Aberdeen) and John McBeth (Keele University, and the
University of Manchester) who allowed use of the EpiFunD dataset. The EpiFunD
study was funded by Arthritis Research UK (formerly the Arthritis Research
Campaign), Grant number: 17552.
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Figure Legends
Fig 1 Anxiety percentile scores generated from the EpiFunD study compared with
those generated from the study providing the currently recommended normative data
from the UK [15]. These are presented for females (a) and males (b) separately
Fig 2 Depression percentile scores generated from the EpiFunD study compared
with those generated from the study providing the currently recommended normative
data from the UK [15]. These are presented for females (a) and males (b) separately
15
Figure 1: Comparison of percentiles (anxiety)
(a): Females
(b): Males
0
3
6
9
12
15
18
21
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Percentile
Crawford et al [15]
EPIFUND
0
3
6
9
12
15
18
21
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Percentile
Crawford et al [15]
EPIFUND
Anx
iety
Sco
re
Anx
iety
sco
re
Figure 2: Comparison of percentiles (depression) (a): Females
(b): Males
0
3
6
9
12
15
18
21
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Percentile
Crawford et al [15]
EPIFUND
0
3
6
9
12
15
18
21
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Percentile
Crawford et al [15]
EPIFUND
Dep
ress
ion
scor
e D
epre
ssio
n sc
ore
Table 1: Demographics of sample
Demographics
Anxiety
(n = 6189)
Depression
(n = 6198)
Anxiety and/or Depression (n = 6232)
Gender Female Male
3491 (56.4) 2698 (43.6)
3503 (56.5) 2695 (43.5)
3519 (56.5) 2713 (43.5)
Age, Mean (SD)
45.9 (11.0)
45.9 (11.0)
45.9 (11.0)
Primary care practice Area A (least affluent) Area B (moderately affluent) Area C (most affluent) Unknown
1342 (21.7) 1746 (28.2) 3096 (50.0)
5 (0.1)
1345 (21.7) 1745 (28.1) 3103 (50.1)
5 (0.1)
1351 (21.7) 1760 (28.2) 3116 (50.0)
5 (0.1) Employment Status
Working full time Working part time Working full time in the home Not working because of ill health/disability Unemployed but seeking work Student Semi-retired Retired Unknown
3269 (52.8) 1023 (16.5)
408 (6.6) 560 (9.1) 120 (1.9) 38 (0.6)
112 (1.8) 511 (8.3) 148 (2.4)
3268 (52.7) 1024 (16.5)
407 (6.6) 568 (9.2) 117 (1.9) 38 (0.6)
114 (1.8) 519 (8.4) 143 (2.3)
3282 (52.7) 1029 (16.5)
409 (6.6) 571 (9.2) 120 (1.9) 38 (0.6)
114 (1.8) 520 (8.3) 149 (2.4)
Marital Status Single Married Other1 Unknown
910 (14.7)
4397 (71.1) 830 (13.4)
52 (0.8)
908 (14.7)
4409 (17.1) 831 (13.4)
50 (0.8)
918 (14.7)
4424 (71.0) 838 (13.5)
52 (0.8)
*Data are presented as number (%) unless otherwise indicated 1Other (separated, divorced and widowed)
Table 2: Anxiety scores by gender and age
Age (yrs) N (%) Median (IQR) Percentage (95% CI)
Mean (SD) Normal (score 0-7)
Mild (score 8-10)
Moderate/Severe (score ≥11)
Females
25-65 3491 6 (4, 9) 61.5-(59.8-63.1) 19.5-(18.2-20.9) 19.0-(17.7-20.4) 6.78-(4.23)
25-29 303 (8.7) 7 (4, 10) 54.5 (48.7-60.2) 21.8 (17.3-26.9) 23.8 (19.1-29.0) 7.18 (4.47)
30-34 485 (13.9) 6 (4, 10) 59.8 (55.3-64.2) 20.0 (16.5-23.8) 20.2 (16.7-24.1) 6.96 (4.27)
35-39 491 (14.1) 6 (3, 9) 62.5 (58.1-66.8) 19.4 (15.9-23.1) 18.1 (14.8-21.8) 6.74 (4.27)
40-44 486 (13.9) 6 (4, 9) 61.7 (57.2-66.1) 18.1 (14.8-21.8) 20.2 (16.7-24.0) 6.88 (4.29)
45-49 451 (12.9) 6 (4, 10) 62.3 (57.7-66.8) 18.0 (14.5-21.8) 19.7 (16.2-23.7) 6.87 (4.19)
50-54 455 (13.0) 6 (4, 9) 61.3 (56.7-65.8) 20.0 (16.4-24.0) 18.7 (15.2-22.6) 6.78 (4.42)
55-59 428 (12.3) 6 (3, 9) 61.4 (56.7-66.1) 21.3 (17.5-25.4) 17.3 (13.8-21.2) 6.59 (4.15)
60-65 392 (11.2) 6 (3, 8) 66.6 (61.7-71.2) 18.4 (14.7-22.6) 15.0 (11.7-19.0) 6.26 (3.90)
Males
25-65 2698 5-(2, 8) 73.6-(71.9-75.3) 13.9-(12.6-15.3) 12.5-(11.3-13.8) 5.51-(4.04)
25-29 174 (6.4) 5 (2, 8) 72.4 (65.1-78.9) 13.8 (9.0-19.8) 13.8 (9.0-19.8) 5.70 (4.47)
30-34 283 (10.5) 5 (2, 8) 71.7 (66.1-76.9) 12.7 (9.1-17.2) 15.6 (11.5-20.3) 5.65 (4.05)
35-39 358 (13.3) 5 (3, 8) 74.0 (69.2-78.5) 14.0 (10.5-18.0) 12.0 (8.8-15.8) 5.59 (3.92)
40-44 371 (13.8) 5 (3, 8) 70.4 (65.4-75.0) 15.6 (12.1-19.7) 14.0 (10.6-18.0) 6.04 (4.12)
45-49 401 (14.9) 5 (3, 8) 71.3 (66.6-75.7) 14.2 (10.9-18.0) 14.5 (11.2-18.3) 5.85 (4.21)
50-54 384 (14.2) 5 (2, 8) 71.6 (66.8-76.1) 14.1 (10.7-17.9) 14.3 (11.0-18.2) 5.59 (4.15)
55-59 367 (13.6) 4 (2, 7) 77.7 (73.0-81.8) 13.1 (9.8-17.0) 9.3 (6.5-12.7) 4.90 (3.80)
60-65 360 (13.3) 4 (2, 7) 79.2 (74.6-83.2) 13.3 (10.0-17.3) 7.5 (5.0-10.7) 4.85 (3.63)
Table 3: Depression scores by gender and age
Age (yrs) N (%) Median (IQR) Percentage (95% CI)
Mean (SD) Normal (score 0-7)
Mild (score 8-10)
Moderate/Severe (score ≥11)
Females
25-65 3503 3 (1, 6) 82.8-(81.5-84.1) 10.3-(9.3-11.3) 6.9-(6.1-7.8) 4.12-(3.78)
25-29 307 (8.8) 3 (1, 6) 83.1 (78.4-87.1) 10.4 (7.2-14.4) 6.5 (4.0-9.9) 3.86 (3.78)
30-34 483 (13.8) 3 (1, 6) 84.5 (80.9-87.6) 9.5 (7.1-12.5) 6.0 (4.1-8.5) 3.92 (3.70)
35-39 490 (14.0) 3 (1, 6) 80.8 (77.0-84.2) 13.1 (10.2-16.4) 6.1 (4.2-8.6) 4.16 (3.83)
40-44 489 (14.0) 3 (1, 7) 80.8 (77.0-84.2) 10.8 (8.2-13.9) 8.4 (6.1-11.2) 4.21 (4.02)
45-49 452 (12.9) 3 (1, 6) 82.1 (78.2-85.5) 10.6 (7.9-13.8) 7.3 (5.1-10.1) 4.28 (3.98)
50-54 455 (13.0) 3 (1, 6) 81.2 (78.1-85.4) 9.9 (7.3-13.0) 8.1 (5.8-11.0) 4.27 (3.91)
55-59 428 (12.2) 3 (1, 6) 85.0 (81.3-88.3) 7.5 (5.2-10.4) 7.5 (5.2-10.4) 4.05 (3.61)
60-65 399 (11.4) 3 (1, 6) 85.0 (81.1-88.3) 10.0 (7.3-13.4) 5.0 (3.1-7.6) 4.07 (3.30)
Males
25-65 2695 3 (1, 6) 84.6-(83.1-85.9) 8.5-(7.5-9.6) 6.9-(6.0-8.0) 3.83-(3.74)
25-29 173 (6.4) 2 (1, 4) 89.0 (83.4-93.3) 6.4 (3.2-11.1) 4.6 (2.0-8.9) 3.04 (3.62)
30-34 285 (10.6) 2 (1, 5) 88.1 (83.7-91.6) 7.0 (4.3-10.6) 4.9 (2.7-8.1) 3.42 (3.38)
35-39 359 (13.3) 3 (1, 5) 89.1 (85.4-92.2) 5.9 (3.7-8.8) 5.0 (3.0-7.8) 3.54 (3.41)
40-44 368 (13.7) 3 (1, 6) 82.9 (78.6-86.6) 8.4 (5.8-11.7) 8.7 (6.0-12.1) 4.04 (3.96)
45-49 402 (14.9) 3 (1, 6) 82.3 (78.3-85.9) 9.7 (7.0-13.0) 8.0 (5.5-11.1) 4.05 (4.02)
50-54 381 (14.1) 3 (1, 6) 80.6 (76.2-84.4) 10.5 (7.6-14.0) 8.9 (6.3-12.2) 4.33 (4.09)
55-59 363 (13.5) 3 (1, 5) 84.6 (80.4-88.1) 8.8 (6.1-12.2) 6.6 (4.3-9.7) 3.76 (3.57)
60-65 364 (13.5) 3 (1, 6) 83.5 (79.3-87.2) 9.6 (6.8-13.1) 6.9 (4.5-10.0) 3.93 (3.56)
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